The effect of mindfulness and metacognition on anxiety symptoms: a case-control study
Middle East Current Psychiatry volume 29, Article number: 95 (2022)
Anxiety disorders (ADs) are associated with numerous psychiatric disorders; despite the efforts in psychotherapy models targeting their etiology, novel treatment strategies are still developing. We aimed to assess whether mindfulness and metacognition differ between patients with ADs and healthy controls (HCs) and whether the symptom severity of ADs is related to mindfulness and metacognition among patients. Two-hundred participants were enrolled in this study. Structured clinical interview, sociodemographic form, Five Facet Mindfulness Questionnaire-Short Form, Metacognition Questionnaire-30, and Hamilton Anxiety Rating Scale were administered. Multivariate analysis of covariance was conducted to compare the groups in terms of mindfulness and metacognition. Correlation and multiple linear regression analyses were performed to measure the association between the variables.
The main finding indicates that positive beliefs about worry are associated with reduced symptom severity of ADs. Furthermore, HCs have more positive beliefs about worry and nonjudging of inner experience compared to patients with ADs, who utilize negative beliefs about uncontrollability and danger and need to control thoughts to a greater extent.
This study demonstrates that dysfunctional metacognitive beliefs may influence the anxiety severity of adult patients. We suggest that focusing on reducing maladaptive metacognitions may be supportive of AD improvement.
Anxiety disorders (ADs) are considered to be among the most widespread psychiatric disorders, and they substantially harm individuals [13, 46, 53, 73, 79, 88]. ADs are assumed to usually start during early adulthood or adolescence . Women were frequently reported to have higher ADs prevalence than men [62, 80]. According to one study, as high as 33.7% of the general population may develop a particular AD during their lifespan , while specific phobias were suggested to be the most prevalent ADs . All ADs are characterized by disproportionate fear (emotional reaction to actual or supposed impending danger), anxiety (expectation of future danger), and associated behavioral problems .
It was proposed that the etiology of ADs is complex and may be related to a variety of individual differences . Additionally, several etiological models of ADs were put forward, drawing attention to both genetic [11, 38, 39, 72, 84] and environmental factors [11, 24, 39, 43]. Due to various distinctive factors, different approaches were suggested for treating ADs, comprising pharmacotherapy, psychotherapy, or a mixture of both. Cognitive-behavioral therapy was suggested to be the most effective type of psychotherapeutic treatment, whereas selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors were recommended as first-line medications for managing ADs [9, 13, 79, 88]. Nevertheless, current pharmacologic treatments do not always yield favorable outcomes for many individuals with ADs .
However, additional studies are necessary to advance the contemporary intervention strategies focusing on the etiology of ADs [61, 83]. Accordingly, we would like to emphasize two factors that are related to each other and have potential contributions to anxiety symptoms: mindfulness and metacognition.
Mindfulness refers to the state of increased awareness, where individuals directly focus on their here and now experiences. This practice may be especially beneficial since it was suggested that people’s daily lives are full of mindless states associated with different detrimental outcomes . The construct of mindfulness was studied extensively in relation to different psychological problems . It was implied that mindfulness might be a prominent factor in each psychotherapy approach .
The existing literature has identified that mindfulness was associated with numerous positive outcomes, such as improved self-esteem [76, 81], empathy [10, 17], sleep quality [42, 111], attention [57, 59], emotional intelligence [63, 91], reduced distress [30, 45], and occupational burnout .
Likewise, mindfulness was shown to be the relevant factor in many ADs, including selective mutism , specific phobia , social anxiety disorder (social phobia) [34, 50, 78], panic disorder [47, 48, 56], and generalized anxiety disorder [28, 40, 48].
While metacognition may be simply explained as “thinking about thinking” , it denotes the advanced way of thinking where individuals exhibit more control over underlying mental processes , and it includes the states of heightened self-regulation and self-awareness . Many people with average intelligence employ metacognitive regulation while dealing with complex mental tasks that demand a higher level of attention . One of the most prominent frameworks that have its origins in metacognitive therapy is the self-regulatory executive function (S-REF) model [106, 107]. S-REF was developed for conceptualizing worry and anxiety-related disorders such as generalized anxiety disorder , posttraumatic stress disorder , and social anxiety disorder . This model suggests that maladaptive metacognitive beliefs trigger unhealthy coping mechanisms (e.g., extended thinking), aggravating mental disorders . According to the S-REF model, a specific thinking style known as cognitive attentional syndrome (CAS) is key to psychological distress. Negative ideas and emotions are perpetuated due to CAS, leading to failures to modify dysfunctional metacognitive beliefs and resolve self-discrepancies in a stable manner .
Metacognitive beliefs are usually separated into positive and negative [100, 101]. The positive metacognitive beliefs refer to the usage of rumination as a specific coping strategy (e.g., “I need to ruminate about my problems to find answers to my anxiety”), whereas the negative metacognitive beliefs represent harm and uncontrollability of rumination, as well as its adverse effects on social functioning (e.g., “Ruminating about my anxiety could make me kill myself”; “Ruminating about my problems is uncontrollable”) . Metacognitive models of ADs suggest that one’s negative beliefs about the danger and uncontrollability of worry may predict the onset and continuance of ADs . These negative appraisals are also called “type 2 worry” or “meta-worry,” and they increase anxiety as these people have a constant need for worrying in order to believe they can deal with a particular situation .
Maladaptive metacognitions were observed in several ADs, encompassing social anxiety disorder (social phobia) [33, 55, 71, 99], panic disorder [4, 22, 68], and generalized anxiety disorder [4, 49, 99, 105].
The associations between mindfulness and metacognition
Mindfulness produces positive treatment outcomes in individuals by utilizing a metacognitive type of information processing , in which individuals may modify how they process information according to the ever-changing circumstances . Moreover, “detached mindfulness” is a technique used in metacognitive therapy. This metacognitive state contains various mechanisms, such as metacognitive control and monitoring, activating metacognitive knowledge, and delaying conceptual processing . Sherwood et al.  have reasoned that those with diminished mindfulness may be at increased risk for developing negative cognitive processes, which often transform into negative metacognitive beliefs. Previous research comparing the neural correlates of metacognition and mindfulness has found that both are linked to increased activity in the anterior cingulate cortex [7, 77, 109], prefrontal cortex [21, 65, 66, 77, 109], and insular cortex [32, 77, 109].
Aims of the study
Although ADs are pervasive and detrimental, their etiology may not be entirely ascertained [61, 83]. Therefore, investigating possible associations between anxiety symptoms and two related cognitive states, mindfulness, and metacognition may pose a different perspective on the developmental origins and treatment modalities of ADs. We aimed to examine whether the symptom severity is connected to mindfulness and metacognition among adults with ADs. To the best of the authors’ knowledge, the association between these variables among adults was not reviewed among the psychiatric population in the existing literature. We hypothesized that low mindfulness and dysfunctional metacognitions might be associated with increased anxiety symptoms. In addition, we hypothesized that mindfulness and metacognition would differ between patients with AD and healthy controls (HC).
Two groups of research participants were recruited for the present study. The patients were selected from the individuals who applied to the psychiatric outpatient unit of the Celal Bayar University Hospital between January and June 2020 if they met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for at least one of the anxiety disorders, including social anxiety disorder, panic disorder, agoraphobia, and generalized anxiety disorder according to the Structured Clinical Interview for DSM-5 . The inclusion criteria for patient selection were as follows: (i) to be between 18 and 65 years of age range, (ii) no current hospital admission, and (3) no treatment change in the last month prior to study participation. The exclusion criteria for patients were as follows: (1) the presence of any psychiatric disorder rather than DSM-5 anxiety disorders class and (2) ineligibility to fill in the self-report questionnaires. Additionally, gender-matched HCs were recruited through advertisements on social networks of the clinic for the present study. HC group also underwent a Structured Clinical Interview for DSM-5 . For HCs, we excluded individuals with psychiatric disorders only. Initially, we reached 100 outpatients and 100 HCs; however, 27 patients were excluded due to having comorbid psychiatric disorders rather than anxiety disorders (n = 19), not responding to all the items in questionnaires (n = 6), and withdrawing the consent (n = 2). Seven HCs were excluded due to lacked or fixed scoring of at least one questionnaire. At the time of the study, all patients were under regular antidepressant and anxiolytic treatment. All participants provided written informed consent, and the study was approved by the Institutional Review Board of Celal Bayar University (Decision no: 20.478.486).
This form was developed to gather the sample’s primary sociodemographic data (including age, gender, education level, and marital status).
Five Facet Mindfulness Questionnaire-Short Form (FFMQ-S)
Five Facet Mindfulness Questionnaire-Short Form (FFMQ-S; ) is the abridged (20 items) version of the original Five Facet Mindfulness Questionnaire (FFMQ) developed by Baer et al. . In FFMQ-S, the statements are scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). FFMQ-S comprises five mindfulness factors like FFMQ: observing (OBS), describing (DES), acting with awareness (ACT), nonjudging of inner experience (NJ), and nonreactivity to inner experience (NR). High scores on FFMQ-S denote a raised level of trait mindfulness. Psychometric properties of FFMQ-S are appropriate in the original version (Cronbach’s alphas for FFMQ-S subscales range from 0.62 to 0.81; ). Similarly, validity and reliability analyses of the Turkish version indicated that FFMQ-S might be utilized among the Turkish sample (Cronbach’s α = 0.71; ). In our study, the range is between 0.71 and 0.79.
Metacognition Questionnaire-30 (MCQ-30)
Metacognition Questionnaire-30 (MCQ-30; ) is the shortened, 30-item version adapted from the Metacognition Questionnaire (MCQ; ) that contains 65 items. MCQ-30 measures individual differences in five prominent factors of the metacognitive model of psychological disorders. These factors are positive beliefs about worry (POS), negative beliefs about uncontrollability and danger (NEG), need to control thoughts (NC), (lack of) cognitive confidence (CC), and cognitive self-consciousness (CSC). The items presented in MCQ-30 are assessed on a 4-point Likert scale, ranging from 1 (do not agree) to 4 (agree very much), and higher scores signify greater levels of maladaptive metacognitions . MCQ-30 has established acceptable both internal consistency and test-retest reliability values (Cronbach’s α = 0.72–0.93, r = 0.59–0.87; ). Turkish version of MCQ-30 has likewise shown good psychometric properties . In our study, Cronbach’s alpha ranged from 0.76 to 0.89.
Hamilton Anxiety Rating Scale (HAM-A)
The Hamilton Anxiety Rating Scale (HAM-A; ) is a clinician-rated scale used to evaluate anxiety symptoms’ severity. HAM-A is still commonly utilized in research and clinical settings due to its versatility: it applies to adult, adolescent, and children populations. HAM-A comprises 14 items, each described by a series of symptoms, and it measures both somatic anxiety (physical complaints linked to anxiety) and psychic anxiety (mental agitation and psychological distress). Each item is scored on a 5-point Likert scale ranging from 0 (not present) to 4 (severe). A total score range is 0–56, where < 17 implies mild severity of anxiety symptoms, 18–24 mild-to-moderate severity, and 25–30 moderate to severe . HAM-A has strong internal consistency (Cronbach’s α = 0.89; ) and good inter-rater reliability as determined by an intra-class correlation coefficient of 0.74–0.96 . In , Yazici et al. confirmed the validity of the Turkish version of HAM-A. We found Cronbach alpha = 0.87 in our study.
Post hoc power analyses using G*Power software version 126.96.36.199 confirmed that we had an adequate sample size to be able to achieve a high level of power and reduce the chance of making a type 2 error, considering α error = .05, f2 = 0.20, and power (1 — β error) = 0.90. Descriptive statistics methods were used to estimate the mean, standard deviation, total count, and frequency of the variables. The normality of distribution was checked by the Shapiro-Wilk test, skewness, and kurtosis. The normality assumptions were fulfilled. Independent samples t-test and chi-square were run to reveal the differences in the sociodemographic variables between HC and AD groups. Multivariate analysis of covariance (MANCOVA) was conducted for controlling covariates (age and marital status) while comparing the groups’ variances in FFMQ-S and MCQ-30 subtests. To measure the relationships between HAM-A-total, FFMQ-S, and MCQ-30 factors, bivariate (Pearson) correlation analyses were executed. Multiple linear regression analysis (enter method used) was subsequently carried out to examine the predictive value of FFMQ-S and MCQ-30 factors for the outcome variable HAM-A-total after verifying that multiple linear regression analysis assumptions were justified. Cohen’s f2 was calculated to determine the effect size of a multiple linear regression model. According to Cohen’s guidelines, f2 ≥ .02, f2 ≥ 0.15, and f2 ≥ 0.35 represent small, medium, and large effect sizes, respectively . The level of statistical significance (p) was set to < .05. Statistical Package for Social Sciences (SPSS) version 22.0 (IBM Corp., Armonk, NY, USA) was utilized for running the statistical analyses.
Characteristics of the groups
The sociodemographic characteristics of the two groups are presented in Table 1. The groups differed in age (t(164) = −5.41, p < .001) and marital status (χ2(2) = 22.38, p < .001). There were no significant differences in education level (t(164) = 1.51, p < 0.133) and gender (χ2(1) = 3.03, p = .082). The results showed that the average HAM-A-total score in the AD patients group (M = 15.9, SD = 6.6) corresponds to the mild severity of anxiety symptoms .
Comparison of the FFMQ-S and MCQ-30 scores between HC and AD groups showing the results from MANCOVA
MANCOVA was used to determine the effects of HC and AD groups on FFMQ-S and MCQ-30 factors. Age and marital status were entered as covariates to control their effects on group differences. There were no statistically significant effects of age (F(10, 153) = 1.24, p = 0.270, ηp2 = .08) and marital status (F(10, 153) = 0.34, p = 0.970, ηp2 = .02) on groups. Statistically, significant group effects were observed in FFMQ-S-NJ (F(1, 162) = 6.03, p = .015, ηp2 = .04), MCQ-30-POS (F(1, 162) = 13.92, p < .001, ηp2 = .08), MCQ-30-NEG (F(1, 162) = 18.60, p < .001, ηp2 = 0.10), and MCQ-30-NC (F(1, 162) = 11.82, p = .001, ηp2 = .07). On contrary, no group effects were obtained in FFMQ-S-ACT (F(1, 162) = 1.58, p = 0.211, ηp2 = .01), FFMQ-S-NR (F(1, 162) = 2.68, p = 0.104, ηp2 = .02), FFMQ-S-OBS (F(1, 162) = 0.77, p = 0.381, ηp2 = .01), FFMQ-S-DES (F(1, 162) = 0.46, p = 0.497, ηp2 < .01), MCQ-30-CC (F(1, 162) = 0.07, p = 0.796, ηp2 < .01), and MCQ-30-CSC (F(1, 162) = 3.07, p = .082, ηp2 = .02). The results are presented in Table 2.
Associations between HAM-A-total, FFMQ-S, and MCQ-30 factors among AD patients group
The bivariate correlation coefficients for the AD patients group are presented in Table 3. HAM-A-total score was negatively correlated with FFMQ-S-NJ (r = −0.27, p = .034) and MCQ-30-POS (r = −0.27, p = .034), while it was positively correlated with MCQ-30-NEG (r = 0.28, p = .029). Results from multiple linear regression analysis (enter method used) are presented in Table 4. MCQ-30-POS was a significant predictor of HAM-A-total (F(3, 69) = 4.00, p = .012), explaining 17.4% of the total variance in the regression model. The effect size of the final regression model was medium (f2 = 0.20).
This study aimed to assess whether mindfulness and metacognition differ between AD patients and HCs and examine the potential contribution of metacognition and mindfulness to anxiety symptoms in adults with AD diagnosis. The results have suggested that patients with AD have utilized negative beliefs about uncontrollability and danger and the need to control thoughts to a greater extent. In contrast, HCs had more positive beliefs about worry and nonjudging of inner experience. Additionally, positive beliefs about worry were associated with decreased symptom severity of ADs, whereas we did not show any relationships between mindfulness and anxiety symptoms.
One finding of this study was that patients with ADs possessed more negative metacognitive beliefs when compared to the HC group. This result is in line with previous studies that have suggested a positive association between negative metacognitive beliefs and anxiety [1, 4, 6, 14, 23, 29, 82, 90]. Negative metacognitive beliefs may incite anxiety when individuals begin catastrophizing about the potential outcomes of worrying . Although the correlation analyses of our sample have shown that negative metacognitive beliefs were positively associated with symptom severity of ADs, this was not confirmed by the multiple linear regression analyses. This finding may potentially be explained by the fact that all patients with ADs in our sample were under regular treatment, and no hospital admission may imply that their anxiety levels were under control, which was supported by the HAM-A scale, according to which they had mild severity of anxiety symptoms . Therefore, it is possible that the results would be different for moderate or severe anxiety.
Another finding our study has indicated is that patients with ADs held more need to control thoughts than HCs, which is a type of negative metacognitive belief . This metacognitive belief represents the lack of control over thoughts which people with ADs may consider a negative experience . Previous research has suggested that the need to control thoughts may relate to heightened anxiety [4, 6, 22, 29, 68, 90, 94, 102]. Individuals with ADs may monitor their internal states and try to eliminate from the consciousness all the thoughts that trigger worry, though this coping strategy is not practical because the use of thought suppression typically intensifies the negative beliefs associated with thought control [103, 110].
In this study, positive beliefs about worry were the only predictor of decreased symptom severity of ADs. This finding was supported by a recent study in which positive beliefs about worry have negatively predicted panic disorder and generalized anxiety disorder . It was suggested that holding positive beliefs about worry is “quite normal” [97, 102] since they are employed in the process of emotion and cognition regulation . Prior studies have proposed that positive metacognitive beliefs do not signal the incidence of ADs, as they alone cannot produce the symptoms of anxiety [70, 90, 98, 102], and they become pathological and may lead to ADs only in the presence of negative metacognitive beliefs [19, 97, 102]. Wells  has argued that positive metacognitive beliefs may reduce anxiety only if individuals successfully meet their internal objectives. According to this, the finding that the HC group in our study has employed more positive metacognitive beliefs may be interpreted so that they were successful in attaining their internal objectives. Furthermore, since patients with ADs have shown mild symptom severity, it may be assumed that they still possess necessary coping mechanisms in positive metacognitive beliefs, which preclude the detrimental effects of negative metacognitive beliefs .
Ostafin et al.  have suggested that individuals high in nonjudging of inner experience do not assess feelings, thoughts, and impulses as good, harmful, or dangerous, nor attempt to alter them . Our findings have presented that nonjudging of inner experience was negatively correlated with symptom severity of ADs, and the HC group has scored higher on this mindfulness factor. These outcomes are consistent with the previous literature indicating the inverse relationship between anxiety and this mindfulness component [16, 27, 31, 37, 69, 74, 85]. However, it should be noted that our regression model did not support these findings. This result may be explained by the fact that the mindfulness scores of our sample (both HCs and patients) are different compared to the scores in the validity and reliability study . The small sample size and subject variables, including age and gender, may account for the observed differences.
This research has a few notable limitations. First, small sample size and nonrandom sampling threaten the validity of our results. Due to the self-report instruments’ application, recall bias and answer accuracy may have influenced our findings. Regardless of our attempt to statistically control extraneous variables, there may have been some overlooked effects of subject variables, such as comorbid physical conditions that may cause anxiety symptoms; therefore, we suggest that future studies consider them as the exclusion criteria. Additionally, given that our sample corresponds to mild severity of anxiety symptoms, it is likely that different results would be observed at different severity stages of the ADs. Moreover, the cross-sectional design of this study cannot identify the cause-and-effect pattern of the observed associations. Future studies should use longitudinal designs to look at the differences in mindfulness and metacognitions over time and pinpoint causal predictors of symptom severity of ADs. Finally, it would have been preferable to assess mindfulness and metacognition among patients with ADs who are not under pharmacological or non-pharmacological treatment to avoid their effects on symptom severity.
In conclusion, this study suggests that positive beliefs about worry may be associated with decreased symptom severity of ADs among adults. Contrary to our expectations, mindfulness was not found to be associated with mild anxiety symptoms. Therefore, we advise that focusing on improving dysfunctional metacognitive beliefs rather than mindfulness may assist more in the maintenance treatment of the adult AD population. Given that this is the initial study on this topic, additional research is required to determine the effects of metacognitive beliefs on adults’ anxiety.
Availability of data and materials
All data generated or analyzed during this study are included in this published article (and its supplementary information files).
Self-regulatory executive function
Cognitive attentional syndrome
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
Five Facet Mindfulness Questionnaire-Short Form
Acting with awareness
Nonjudging of inner experience
Nonreactivity to inner experience
Positive beliefs about worry
Negative beliefs about uncontrollability and danger
Need to control thoughts
Hamilton Anxiety Rating Scale
Multivariate analysis of covariance
Statistical Package for Social Sciences
Anderson R, Capobianco L, Fisher P, Reeves D, Heal C, Faija CL, Gaffney H, Wells A (2019) Testing relationships between metacognitive beliefs, anxiety and depression in cardiac and cancer patients: are they transdiagnostic? J Psychosomatic Res 124:109738. https://doi.org/10.1016/j.jpsychores.2019.109738
Association AP (2013) Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub
Ayalp HD, Hisli Şahin N (2018) Beş Faktörlü Bilgece Farkındalık Ölçeği-Kısa Formu’nun (BFBFÖ-K) Türkçe Uyarlaması. Klinik Psikoloji Dergisi 2(3):117–127
Aydın O, Balıkçı K, Çökmüş FP, Ünal Aydın P (2019) The evaluation of metacognitive beliefs and emotion recognition in panic disorder and generalized anxiety disorder: effects on symptoms and comparison with healthy control. Nordic J Psychiatry 73(4–5):293–301
Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L (2006) Using self-report assessment methods to explore facets of mindfulness. Assessment 13(1):27–45
Bailey R, Wells A (2015) Metacognitive beliefs moderate the relationship between catastrophic misinterpretation and health anxiety. J Anxiety Disord 34:8–14. https://doi.org/10.1016/j.janxdis.2015.05.005
Baird B, Smallwood J, Gorgolewski KJ, Margulies DS (2013) Medial and lateral networks in anterior prefrontal cortex support metacognitive ability for memory and perception. J Neurosci 33(42):16657–16665
Bandelow B, Michaelis S (2015) Epidemiology of anxiety disorders in the 21st century. Dialogues Clin Neurosci 17(3):327
Bandelow B, Michaelis S, Wedekind D (2017) Treatment of anxiety disorders. Dialogues Clin Neurosci 19(2):93
Beddoe AE, Murphy SO (2004) Does mindfulness decrease stress and foster empathy among nursing students? J Nurs Educ 43(7):305–312
Bolton D, Eley TC, O’Connor TG, Perrin S, Rabe-Hesketh S, Rijsdijk F, Smith P (2006) Prevalence and genetic and environmental influences on anxiety disorders in 6-year-old twins. Psychol Med 36(3):335
Bruss GS, Gruenberg AM, Goldstein RD, Barber JP (1994) Hamilton Anxiety Rating Scale interview guide: joint interview and test-retest methods for interrater reliability. Psychiatry Res 53(2):191–202
Bystritsky A, Khalsa SS, Cameron ME, Schiffman J (2013) Current diagnosis and treatment of anxiety disorders. Pharmacy Therapeutics 38(1):30
Capobianco L, Faija C, Husain Z, Wells A (2020) Metacognitive beliefs and their relationship with anxiety and depression in physical illnesses: a systematic review. PLoS ONE 15(9 September):e0238457. https://doi.org/10.1371/journal.pone.0238457
Cartwright-Hatton S, Wells A (1997) Beliefs about worry and intrusions: the Meta-Cognitions Questionnaire and its correlates. J Anxiety Disord 11(3):279–296. https://doi.org/10.1016/S0887-6185(97)00011-X
Cash M, Whittingham K (2010) What facets of mindfulness contribute to psychological well-being and depressive, anxious, and stress-related symptomatology? Mindfulness 1(3):177–182
Centeno RPR, Fernandez KTG (2020) Effect of mindfulness on empathy and self-compassion: an adapted MBCT program on filipino college students. Behav Sci 10(3):61
Cohen J (1988) Statistical power analysis for the behavioral sciences. Lawrence 403 Erlbaum Associates. Inc., Hillsdale
Cook SA, Salmon P, Dunn G, Fisher P (2014) Measuring metacognition in cancer: validation of the Metacognitions Questionnaire 30 (MCQ-30). PloS One 9(9):e107302
Creswell JD (2017) Mindfulness interventions. Annu Rev Psychol 68:491–516
Creswell JD, Way BM, Eisenberger NI, Lieberman MD (2007) Neural correlates of dispositional mindfulness during affect labeling. Psychosom Med 69(6):560–565
Cucchi M, Bottelli V, Cavadini D, Ricci L, Conca V, Ronchi P, Smeraldi E (2012) An explorative study on metacognition in obsessive-compulsive disorder and panic disorder. Compr Psychiatry 53(5):546–553
Debbané M, Van der Linden M, Balanzin D, Billieux J, Eliez S (2012) Associations among metacognitive beliefs, anxiety and positive schizotypy during adolescence. J Nervous Mental Disease 200(7):620–626
Degnan KA, Almas AN, Fox NA (2010) Temperament and the environment in the etiology of childhood anxiety. J Child Psychol Psychiatry 51(4):497–517
Duffy M, Therapy C (1995) A cognitive model for. In: Social phobia: Diagnosis, assessment, and treatment, vol 69. The Guilford Press, New York, p 1025
Elbir M, Alp Topbaş Ö, Bayad S, Kocabaş T, Zülkif Topak O, Çetin Ş, Özdel O, Ateşçi F, Aydemir Ö (2019) Adaptation and reliability of the structured clinical interview for DSM-5-disorders - clinician version (SCID-5/CV) to the Turkish language. Turk Psikiyatri Dergisi 30(1). https://doi.org/10.5080/u23431
Esch T, Fricchione GL, Joos S, Teut M (2013) Self-care, stress management, and primary care: from salutogenesis and health promotion to mind-body medicine. Hindawi
Evans S, Ferrando S, Findler M, Stowell C, Smart C, Haglin D (2008) Mindfulness-based cognitive therapy for generalized anxiety disorder. J Anxiety Disord 22(4):716–721
Fisher PL, Noble AJ (2017) Anxiety and depression in people with epilepsy: the contribution of metacognitive beliefs. Seizure 50:153–159
Garland EL, Gaylord SA, Fredrickson BL (2011) Positive reappraisal mediates the stress-reductive effects of mindfulness: an upward spiral process. Mindfulness 2(1):59–67
Gautam, A., Polizzi, C. P., & Mattson, R. E. (2019). Mindfulness, procrastination, and anxiety: assessing their interrelationships. Psychology of Consciousness: Theory, Research, and Practice.
Gibson J (2019) Mindfulness, interoception, and the body: a contemporary perspective. Front Psychol 10:2012
Gkika S, Wittkowski A, Wells A (2018) Social cognition and metacognition in social anxiety: a systematic review. Clin Psychol Psychother 25(1):10–30. https://doi.org/10.1002/cpp.2127
Goldin PR, Gross JJ (2010) Effects of mindfulness-based stress reduction (MBSR) on emotion regulation in social anxiety disorder. Emotion 10(1):83
Good DJ, Lyddy CJ, Glomb TM, Bono JE, Brown KW, Duffy MK, Baer RA, Brewer JA, Lazar SW (2016) Contemplating mindfulness at work: An integrative review. Journal of management 42(1):114-142
Hamilton MAX (1959) The assessment of anxiety states by rating. Br J Med Psychol 32(1):50–55
Hawley LL, Rogojanski J, Vorstenbosch V, Quilty LC, Laposa JM, Rector NA (2017) The structure, correlates, and treatment related changes of mindfulness facets across the anxiety disorders and obsessive compulsive disorder. J Anxiety Disord 49:65–75
Hettema JM, Neale MC, Kendler KS (2001) A review and meta-analysis of the genetic epidemiology of anxiety disorders. Am J Psychiatry 158(10):1568–1578
Hettema JM, Prescott CA, Myers JM, Neale MC, Kendler KS (2005) The structure of genetic and environmental risk factors for anxiety disorders in men and women. Arch Gen Psychiatry 62(2):182–189
Hoge EA, Bui E, Marques L, Metcalf CA, Morris LK, Robinaugh DJ, Worthington JJ, Pollack MH, Simon NM (2013) Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity. J Clin Psychiatry 74(8):786–792
Hooper N, Davies N, Davies L, McHugh L (2011) Comparing thought suppression and mindfulness as coping techniques for spider fear. Conscious Cogn 20(4):1824–1830
Howell AJ, Digdon NL, Buro K, Sheptycki AR (2008) Relations among mindfulness, well-being, and sleep. Person Individual Diff 45(8):773–777
Hudson JL, Rapee RM (2009) Familial and social environments in the etiology and maintenance of anxiety disorders. Oxford Handbook of Anxiety and Related Disorders, pp 173–189
Jacobi F, Höfler M, Strehle J, Mack S, Gerschler A, Scholl L, Busch MA, Maske U, Hapke U, Gaebel W (2014) Mental disorders in the general population: study on the health of adults in Germany and the additional module mental health (DEGS1-MH). Der Nervenarzt 85(1):77–87
Jain S, Shapiro SL, Swanick S, Roesch SC, Mills PJ, Bell I, Schwartz GER (2007) A randomized controlled trial of mindfulness meditation versus relaxation training: effects on distress, positive states of mind, rumination, and distraction. Ann Behav Med 33(1):11–21
Kadri N, Agoub M, El Gnaoui S, Berrada S, Moussaoui D (2007) Prevalence of anxiety disorders: a population-based epidemiological study in metropolitan area of Casablanca, Morocco. Ann Gen Psychiatry 6(1):1–6
Kim B, Lee S-H, Kim YW, Choi TK, Yook K, Suh SY, Cho SJ, Yook K-H (2010) Effectiveness of a mindfulness-based cognitive therapy program as an adjunct to pharmacotherapy in patients with panic disorder. J Anxiety Disord 24(6):590–595
Kim YW, Lee S, Choi TK, Suh SY, Kim B, Kim CM, Cho SJ, Kim MJ, Yook K, Ryu M (2009) Effectiveness of mindfulness-based cognitive therapy as an adjuvant to pharmacotherapy in patients with panic disorder or generalized anxiety disorder. Depression Anxiety 26(7):601–606
King AP, Erickson TM, Giardino ND, Favorite T, Rauch SAM, Robinson E, Kulkarni M, Liberzon I (2013) A pilot study of group mindfulness-based cognitive therapy (MBCT) for combat veterans with posttraumatic stress disorder (PTSD). Depression Anxiety 30(7):638–645
Kocovski NL, Fleming JE, Rector NA (2009) Mindfulness and acceptance-based group therapy for social anxiety disorder: an open trial. Cogn Behav Pract 16(3):276–289
Kudesia RS (2019) Mindfulness as metacognitive practice. Acad Manag Rev 44(2):405–423
Kummer A, Cardoso F, Teixeira AL (2010) Generalized anxiety disorder and the Hamilton Anxiety Rating Scale in Parkinson’s disease. Arquivos de Neuro-Psiquiatria 68(4):495–501
Kupfer DJ (2015) Anxiety and DSM-5. Dialogues in Clinical Neuroscience 17(3):245
Lai ER (2011) Metacognition: a literature review. Always Learning: Pearson Research Report, vol 24, pp 1–40
Lakshmi J, Sudhir PM, Sharma MP, Math SB (2016) Effectiveness of metacognitive therapy in patients with social anxiety disorder: a pilot investigation. Indian J Psychol Med 38(5):466–471
Lee S-Y, Lyu S-J, Choi S-Y, Lyu Y-S, Kang H-W (2014) A study on the clinical effects of group therapy for panic disorder patients based on mindfulness & Li-Gyeung-Byun-Qi therapy. J Oriental Neuropsychiatry 25(4):319–332
Lesiuk T (2015) The effect of mindfulness-based music therapy on attention and mood in women receiving adjuvant chemotherapy for breast cancer: a pilot study. Oncol Nurs Forum 42(3):276-282
Livingston JA (2003) Metacognition: An Overview
Mak C, Whittingham K, Cunnington R, Boyd RN (2018) Effect of mindfulness yoga programme MiYoga on attention, behaviour, and physical outcomes in cerebral palsy: a randomized controlled trial. Dev Med Child Neurol 60(9):922–932
Martin, J. R. (1997). Limbering across cognitive-behavioral, psychodynamic and systems orientations. JR Martin (Chair), Retooling for Integration: Perspectives on the Training of Post-Licensed Psychotherapists. Symposium Presented at the 13th Annual Conference of the Society for the Exploration of Psychotherapy Integration, Toronto, Canada.
Mathew AR, Pettit JW, Lewinsohn PM, Seeley JR, Roberts RE (2011) Co-morbidity between major depressive disorder and anxiety disorders: shared etiology or direct causation? Psychol Med 41(10):2023
McLean CP, Asnaani A, Litz BT, Hofmann SG (2011) Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. J Psychiatric Res 45(8):1027–1035
Miao C, Humphrey RH, Qian S (2018) The relationship between emotional intelligence and trait mindfulness: a meta-analytic review. Person Individual Diff 135:101–107
Mineka S, Zinbarg R (2006) A contemporary learning theory perspective on the etiology of anxiety disorders: it’s not what you thought it was. Am Psychol 61(1):10
Molenberghs P, Trautwein F-M, Böckler A, Singer T, Kanske P (2016) Neural correlates of metacognitive ability and of feeling confident: a large-scale fMRI study. Soc Cogn Affect Neurosci 11(12):1942–1951
Morales J, Lau H, Fleming SM (2018) Domain-general and domain-specific patterns of activity supporting metacognition in human prefrontal cortex. J Neurosci 38(14):3534–3546
Mori D (2016) Examining mindfulness based practices and mindfulness based stress reduction in supporting selectively mute students. City University of Seattle
Morrison AP, Wells A (2003) A comparison of metacognitions in patients with hallucinations, delusions, panic disorder, and non-patient controls. Behav Res Ther 41(2):251–256. https://doi.org/10.1016/S0005-7967(02)00095-5
Naliboff BD, Smith SR, Serpa JG, Laird KT, Stains J, Connolly LS, Labus JS, Tillisch K (2020) Mindfulness-based stress reduction improves irritable bowel syndrome (IBS) symptoms via specific aspects of mindfulness. Neurogastroenterol Motility 32(9):e13828
Nieto MÁP, Delgado MMR, Mateos LL, Bueno N (2010) Cognitive control and anxiety disorders: metacognitive beliefs and strategies of control thought in GAD and OCD. Clinica y Salud 21(2):159–166
Nordahl H, Wells A (2018) Metacognitive therapy for social anxiety disorder: an A-B replication series across social anxiety subtypes. Front Psychol 9(APR):540. https://doi.org/10.3389/fpsyg.2018.00540
Ohi K, Otowa T, Shimada M, Sasaki T, Tanii H (2020) Shared genetic etiology between anxiety disorders and psychiatric and related intermediate phenotypes. Psychol Med 50(4):692–704
Olatunji BO, Cisler JM, Tolin DF (2007) Quality of life in the anxiety disorders: a meta-analytic review. Clin Psychol Rev 27(5):572–581
Ostafin BD, Brooks JJ, Laitem M (2014) Affective reactivity mediates an inverse relation between mindfulness and anxiety. Mindfulness 5(5):520–528
Papageorgiou C, Wells A (2001) Positive beliefs about depressive rumination: development and preliminary validation of a self-report scale. Behav Ther 32(1):13–26. https://doi.org/10.1016/S0005-7894(01)80041-1
Pepping CA, O’Donovan A, Davis PJ (2013) The positive effects of mindfulness on self-esteem. J Positive Psychol 8(5):376–386
Qiu L, Su J, Ni Y, Bai Y, Zhang X, Li X, Wan X (2018) The neural system of metacognition accompanying decision-making in the prefrontal cortex. PLoS Biology 16(4):e2004037
Rasmussen MK, Pidgeon AM (2011) The direct and indirect benefits of dispositional mindfulness on self-esteem and social anxiety. Anxiety Stress Coping 24(2):227–233
Ravindran LN, Stein MB (2010) The pharmacologic treatment of anxiety disorders: a review of progress. J Clin Psychiatry 71(7):839–854
Remes O, Brayne C, Van Der Linde R, Lafortune L (2016) A systematic review of reviews on the prevalence of anxiety disorders in adult populations. Brain Behav 6(7):e00497
Salekin RT, Worley C, Grimes RD (2010) Treatment of psychopathy: a review and brief introduction to the mental model mpproach for psychopathy. Behav Sci Law 28(2):235–266
Sherwood A, Carydias E, Whelan C, Emerson L-M (2020) The explanatory role of facets of dispositional mindfulness and negative beliefs about worry in anxiety symptoms. Person Individual Diff 160:109933
Sild M, Ruthazer ES, Booij L (2017) Major depressive disorder and anxiety disorders from the glial perspective: etiological mechanisms, intervention and monitoring. Neurosci Biobehav Rev 83:474–488
Smoller JW (2016) The genetics of stress-related disorders: PTSD, depression, and anxiety disorders. Neuropsychopharmacology 41(1):297–319
Soysa CK, Wilcomb CJ (2015) Mindfulness, self-compassion, self-efficacy, and gender as predictors of depression, anxiety, stress, and well-being. Mindfulness 6(2):217–226
Spada MM, Caselli G, Nikčević AV, Wells A (2015) Metacognition in addictive behaviors. Addict Behav 44:9–15. https://doi.org/10.1016/j.addbeh.2014.08.002
Spada MM, Mohiyeddini C, Wells A (2008) Measuring metacognitions associated with emotional distress: factor structure and predictive validity of the metacognitions questionnaire 30. Person Individual Diff 45(3):238–242. https://doi.org/10.1016/j.paid.2008.04.005
Ströhle A, Gensichen J, Domschke K (2018) The diagnosis and treatment of anxiety disorders. Deutsches Ärzteblatt Int 115(37):611
Sulaiman T, Rahim A, Syrene S, Yan K (2021) Primary science teachers’ perspectives about metacognition in science teaching. Eur J Educ Res 10(1):75–84
Sun X, Zhu C, So SHW (2017) Dysfunctional metacognition across psychopathologies: a meta-analytic review. In: European Psychiatry, vol 45. Elsevier, pp 139–153. https://doi.org/10.1016/j.eurpsy.2017.05.029
Teal C, Downey LA, Lomas JE, Ford TC, Bunnett ER, Stough C (2019) The role of dispositional mindfulness and emotional intelligence in adolescent males. Mindfulness 10(1):159–167
Tosun A, Irak M (2008) Üstbiliş Ölçeği-30’un Türkçe Uyarlaması, Geçerliği, Güvenirliği, Kaygı ve Obsesif-Kompülsif Belirtilerle İlişkisi. Turk Psikiyatri Dergisi 19(1):67–80
Tran US, Glück TM, Nader IW (2013) Investigating the Five Facet Mindfulness Questionnaire (FFMQ): construction of a short form and evidence of a two-factor higher order structure of mindfulness. J Clin Psychol 69(9):951–965
Wells A (2006) Worry and Its Psychological Disorders: Theory, Assessment and Treatment
Wells A (1995) Meta-cognition and worry: a cognitive model of generalized anxiety disorder. Behav Cogn Psychother 23(3):301–320. https://doi.org/10.1017/S1352465800015897
Wells, Adrian. (2002). GAD, metacognition, and mindfulness: an information processing analysis. In Clinical Psychology: Science and Practice. 9(1):95–100. Wiley Online Library. https://doi.org/10.1093/clipsy/9.1.95
Wells A (2005) Detached mindfulness in cognitive therapy: a metacognitive analysis and ten techniques. J Rational Emotive Cogn Behav Ther 23(4):337–355. https://doi.org/10.1007/s10942-005-0018-6
Wells A (2005) The metacognitive model of GAD: assessment of meta-worry and relationship with DSM-IV generalized anxiety disorder. Cogn Ther Res 29(1):107–121. https://doi.org/10.1007/s10608-005-1652-0
Wells A (2007) Cognition about cognition: metacognitive therapy and change in generalized anxiety disorder and social phobia. Cogn Behav Pract 14(1):18–25. https://doi.org/10.1016/j.cbpra.2006.01.005
Wells A (2008) Emotional disorders and metacognition: innovative cognitive therapy. In: Emotional Disorders and Metacognition: Innovative Cognitive Therapy. Wiley. https://doi.org/10.1002/9780470713662
Wells A (2008) The metacognitive model of worry and generalised anxiety disorder. In: Worry and its Psychological Disorders: Theory, Assessment and Treatment. Wiley Chichester, England, pp 177–199. https://doi.org/10.1002/9780470713143.ch11
Wells A, Carter K (2001) Further tests of a cognitive model of generalized anxiety disorder: metacognitions and worry in gad, panic disorder, social phobia, depression, and nonpatients. Behav Ther 32(1):85–102. https://doi.org/10.1016/S0005-7894(01)80045-9
Wells A, Carter KEP (2009) Maladaptive thought control strategies in generalized anxiety disorder, major depressive disorder, and nonpatient groups and relationships with trait anxiety. Int J Cogn Ther 2(3):224–234. https://doi.org/10.1521/ijct.2009.2.3.224
Wells A, Cartwright-Hatton S (2004) A short form of the metacognitions questionnaire: properties of the MCQ-30. Behav Res Ther 42(4):385–396. https://doi.org/10.1016/S0005-7967(03)00147-5
Wells A, King P (2006) Metacognitive therapy for generalized anxiety disorder: an open trial. J Behav Ther Exp Psychiatry 37(3):206–212. https://doi.org/10.1016/j.jbtep.2005.07.002
Wells A, Matthews G (1996) Modelling cognition in emotional disorder: the S-REF model. Behav Res Ther 34(11–12):881–888. https://doi.org/10.1016/S0005-7967(96)00050-2
Wells A, Matthews G (2014) Attention and emotion (Classic edition): a clinical perspective. In: Attention and Emotion (Classic Edition): A clinical perspective. Psychology Press. https://doi.org/10.4324/9781315747187
Wells A, Sembi S (2004) Metacognitive therapy for PTSD: a preliminary investigation of a new brief treatment. J Behav Ther Exp Psychiatry 35(4):307–318. https://doi.org/10.1016/j.jbtep.2004.07.001
Wheeler MS, Arnkoff DB, Glass CR (2017) The neuroscience of mindfulness: how mindfulness alters the brain and facilitates emotion regulation. Mindfulness 8(6):1471–1487
Wenzlaff RM, Wegner DM (2000) Thought suppression. Annual review of psychology 51(1):59-91
Winbush NY, Gross CR, Kreitzer MJ (2007) The effects of mindfulness-based stress reduction on sleep disturbance: a systematic review. Explore 3(6):585–591
Xie C, Li X, Zeng Y, Hu X (2020) Mindfulness, emotional intelligence and occupational burnout in intensive care nurses: a mediating effect model. J Nurs Manag 29(3):535-542
Yazici MK, Demir B, Tanriverdi N, Karaagaoglu E, Yolac P (1998) Hamilton Anxiety Rating Scale: interrater reliability and validity study. Turk Psikiyatri Derg 9(2):114–117
Zwanzger P, Singewald N, Bandelow B (2021) Pharmacotherapy of anxiety disorders-guideline-conform treatment and new developments. Der Nervenarzt 92(5):433–440
The participants in this study are all gratefully acknowledged by the authors. The abstract of this paper was presented at the 30th European Congress of Psychiatry held online from June 4 to 7, 2022.
The study received no funding.
Ethics approval and consent to participate
Informed consent was obtained from all individual participants included in the study. All procedures performed in the study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. The study was approved by the Institutional Review Board of Celal Bayar University (No. 20.478.486).
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Aydın, O., Obuća, F., Çakıroğlu, E. et al. The effect of mindfulness and metacognition on anxiety symptoms: a case-control study. Middle East Curr Psychiatry 29, 95 (2022). https://doi.org/10.1186/s43045-022-00260-7
- Metacognitive beliefs